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Correction of entropion from Stevens-Johnson syndrome: use of nasal septum and mucosa for severely cicatrized eyelid entropion.

The resistant entropion, especially of the upper lid, that results from the persistent contraction of the conjunctiva after Stevens-Johnson syndrome is difficult to correct. Grafts of buccal mucosa have relieved this condition for only a few weeks or months. Because of the rigidity of the nasal septum, a sector of this structure, with the perichondrium and mucosa intact on one side, has been grafted into the posterior layer of the upper lid at the margin to turn the lashes and skin away from the globe. For more than two years postoperatively, this graft of septal mucosa has relieved patients of their entropion, and from all indications this correction will be permanent.

Conjunctiva

Medial entropion following orbital decompression for dysthyroid ophthalmopathy.

We found medial entropion of the lower eyelid to be common following orbital decompression for dysthyroid opthalmopathy. In our series significant postoperative medial entropion was noted in 14 of 69 patients, an incidence of 20%. Only four of these patients had entropion severe enough to require surgery (6%). Before orbital decompression, only one patient was found to have significant medial entropion (1.4%). Analysis of associated factors disclosed a positive relation between the amount of operative proptosis reduction and the degree of postoperative medial entropion. A strong correlation was also observed with the type of approach; transantral surgery was much more likely to be associated with significant postoperative medial entropion than was transconjunctival surgery. We suggest that the inferomedial displacement of the muscle cone that follows orbital decompression results in a force vector, transmitted through the lower eyelid retractors and capsulopalpebral ligament, that intorts the medial lower eyelid. Medial entropion in this setting often coexists with lower eyelid retraction, and if a "spacer" of sclera or ear cartilage is to be inserted into the lower eyelid, it should be carried into the medialmost portion of the eyelid to recess the posterior lamellae, including the medial retractors, and allow the eyelid margin to return to its normal anatomic position.

Entropion

A comparative study of eyelid parameters in involutional entropion.

A comparative study of eyelid parameters reported to be important in involutional entropion was made. Males and females aged greater than or equal to 65 years with normal eyelids, acute involutional entropion (history less than 6 weeks), and chronic involutional entropion (history greater than or equal to 6 weeks) were entered into the study. Significant findings were increased vertical laxity in each entropion group and increased horizontal laxity in the chronic entropion group. The upper eyelid action had an essential role in the turning in of affected lower eyelids. The degree of pretarsal overriding in the lower eyelid was not a significant differentiating feature when the groups were compared. The findings of this comparative study provide the basis for suggesting the pathophysiology of involutional entropion.

Aged

Involutional entropion of the upper lid.

Involutional entropion is an inturning of the eyelid margin caused by changes of lid tissues due to aging. Two patients with the uncommon finding of involutional entropion of the upper lid were treated with surgery based on the principles used to treat common lower lid entropion. The causes of lower lid entropion include increased horizontal and vertical lid laxity, and correcting these same factors in the upper lid resulted in a satisfactory repair of the entropion. Treatment of involutional entropion in the upper lid is compared and contrasted with that of the lower lid.

Aged

[Entropion in newborn lambs].

The Entropion in newborn lambs could be proved so far in 8 sheep-breeds and 7 cross-breeds out of 33 flocks in the Federal Republic of Germany. In our patients the Entropion was found at the lower eyelid only. The owners of the animals often mistake the Entropion for an ophthalmia. An early diagnosis and an early beginning of the therapy keep the expenditure of treatment small and shorten the period of treatment; therefore examination is commendable within a short time after birth. Female lambs get clearly more often affected than male ones (Gynecotropia). In small pure-bred flocks with only one breeding-ram (and also in breeds with a limited population) the percentage of suffering lambs is higher than in large and crossed flocks with several rams and in large populations (except the breed "Heidschnucke"). In agreement with the literature it must be supposed that different genes are responsible for the Entropion. The selection of ill animals and those which are suspected of transmitting the disposition is evidently appropriate to lower the number of attacks of illness within a population considerably. All 47 affected eyes of 32 lambs were treated. Low degrees of Entropion were healed by repeated manual eversion plus application of antibiotic eye-ointment. In middle and high degrees of Entropion the application of Michel-wound-clamps on 23 of 26 eyes was successful; antibiotic eye-ointment was applied here, too; additionally these lambs prophylactically got 2000 I.U. of Tetanus-antitoxin.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals

Tarsotomy for the treatment of cicatricial entropion with trichiasis.

Transverse tarsotomy and lid margin rotation is a simple procedure that is effective in repositioning the entropic lid margin without requiring external incisions or grafting. We report the results of this procedure in 81 eyelids of 58 patients with cicatricial entropion and trichiasis who were followed up for a minimum of 6 months after surgery. Fifty-nine (94%) of sixty-three eyelids with mild to moderate cicatricial entropion were cured with this procedure. Patients with severe cicatricial entropion had a lower success rate with initial tarsotomy (55%), but in these patients the procedure had minimal complications and repeating the operation resulted in a higher success rate. Tarsotomy and lid margin rotation produces excellent cosmetic and functional results when used to treat patients with mild to moderate cicatricial entropion. In cases of more severe cicatricial entropion, we still recommend it as the initial procedure after which more complex modalities may be used if needed.

Adolescent

Association of entropion with cataract surgery.

Ptosis may develop after cataract surgery because of a dehiscence of the levator aponeurosis. A series of patients undergoing entropion repair was examined in order to determine the mechanism of entropion and the correlation with cataract surgery. It is suggested that involutional senile entropion may develop related to cataract surgery, on the same basis as ptosis, due to disinsertion of the capsulopalpebral fascia. It is suggested that the cataract surgeon should examine the patient closely for preoperative entropion to prevent or anticipate the development of frank entropion after the cataract surgery.

Adult

Combined procedure for repair of involutional entropion.

Combined procedures that address multiple etiologic factors in involutional entropion are not new, but ophthalmic surgeons have been slow to accept this surgical approach. Traditional procedures that correct only one or two of the etiologic factors have a high incidence of recurrent entropion. The purpose of this article is to encourage the use of a combined procedure in the treatment of all cases of primary and recurrent entropion to minimize recurrences. Between 1983 and 1989, 127 consecutive eyelids with involutional entropion in 97 patients were operated by the senior author (R.P.C.) using the procedure described in this paper. Of these eyelids, 39% (49) had previous surgery and 22% (28) had more than one previous procedure. Although occasional minor postoperative problems occurred, they were readily managed, and there have been no known recurrences of entropion with an average follow-up of 33 months.

Entropion

Tarsal grafting for correction of cicatricial entropion.

A technique of tarsal grafting was used as a simple yet effective procedure for the correction of upper-lid cicatricial entropion. A tarsal graft, 3 to 4 mm in height, excised from the superior tarsus of the donor upper eyelid and placed in a marginal tarsotomy, vertically expands the posterior lamella of the involved lid. This graft also provides a base for suture fixation of the everted lid margin. One case of unilateral cicatricial entropion corrected with a contralateral tarsal graft and one case of bilateral cicatricial entropion corrected by ipsilateral tarsal grafting demonstrate results obtained with this technique. Functional and cosmetically satisfactory results have been achieved with this technique. No recurrence of cicatricial entropion has been noted. With this procedure, tarsus provides excellent graft material for correction of the eyelid deformities associated with cicatricial entropion.

Adult

[Schimek's method of correcting senile entropion (author's transl)].

Laxity of skin and tissue over the tarsal plate and spasm of the orbicular muscle along the lid margin lead to senile entropion. The lashes rub against the cornea and this irritation incites further lid spasm. The inferior margin of the tarsus everts easily and in strong cases of entropion the tarsal plate has turned 180 degrees. In 1957 Schimek described a method of correcting senile entropion by a permanently buried horizontal suture which runs from the medial part of the orbicular muscle to the periost of temporal orbital margin. This suture tightens the orbicular muscle and tarsoorbital fascia and provides eversion of the lower border of the tarsus. We have done this operation in 36 patients and were able to examine 24 of them (29 eyes) after a period of one month to 5 years after operation. In 21 patients we noted good results, in 8 cases we found a recurrence of entropion, which means a relatively high recidivity rate with this method.

Aged

Congenital primary upper eyelid entropion.

A case of primary congenital upper eyelid entropion ( PCUEE ) is reviewed. The author proposes a congenital shortness of the levator muscle with anomalous insertion onto the tarsal plate as the etiology, and a new simplified surgical correction is described. The classification of PCUEE as a syndrome with multiple congenital anomalies is supported, and the need for a complete systemic evaluation is stressed. Congenital primary upper eyelid entropion is an exceedingly rare condition. In 1969, Hiles and Wilder reviewed the 13 known cases in the ophthalmic literature, and presented a new case. They suggested the possibility that congenital upper eyelid entropion was part of a syndrome involving multiple systemic anomalies. Surgical correction of the ectropion is usually necessitated by corneal erosion secondary to trichiasis, and a multifarious assortment of surgical procedures has been described. The following is a case report of primary congenital upper eyelid entropion which corroborates the categorization as a syndrome, suggests a pathophysiologic abnormality of the eyelid as the etiology, and describes a new, simplified technique of surgical repair.

Abnormalities, Multiple

Spastic entropion after cataract surgery.

Spastic entropion is an acute eyelid condition seen in patients with acute inflammatory ocular conditions. It has been reported after cataract surgery. We describe three cases of spastic entropion after cataract surgery that did not resolve after the ocular irritation subsided. All were associated with eyelid and/or cul-de-sac injection of antibiotics and corticosteroids or anesthetic solution. All had dehiscence of the capsulopalpebral fascia. Spastic entropion is an evolving stage toward permanent entropion.

Aged

[Entropion: therapeutic indications].

The severity of entropion depends on trichiasis which is perpetuated by orbicularis spasm, creating a vicious cycle. The therapeutic approaches are based on the aetiopathogenesis. Congenital entropion is essentially treated by infraciliary cutaneomuscular resection. The various components of involutional (senile) entropion, horizontal and vertical retraction, orbicularis dyskinesia, are treated respectively by tissue reduction, reinforcement of retractore and myoplasties. In cicatricial entropion, chondro-mucosal or fibromuscular graft is the technique of choice for correcting insufficiency of the tarsoconjunctival plane or its curvature. It is also the best solution for the correction of trichiasis or distichiasis.

Burns, Chemical

Senile ectropion and entropion: a comparative histopathological study.

A microscopic histopathological study was done on 500 full-eyelid-thickness surgical specimens: 25 with the diagnosis of senile ectropion and 25 with that of senile entropion. Five different staining techniques were used. There appears to be significantly more orbicularis and Riolan's muscle ischemia, atrophy, and collagen fragmentation with ectropion than with entropion. Entropion shows more septal and tarsal atrophy. In both conditions, the skin and conjunctiva show chronic inflammation and scarring as a constant feature. Statistical significance at the 1% level was present for all six characteristics studied. These histopathological changes, if not etiological, are at least concomitant features differentiating senile ectropion from entropion at the microscopic tissue level.

Aged

The "corncrib" repair of senile entropion.

A new method of senile entropion repair has been described. The method corrects the entropion by affecting those conditions which create an entropion: enophthalmos, lid laxity, preseptal orbicularis movement, and retractor weakness. A 3.4% recurrence rate in 58 lids followed an average 17 months was found. This procedure is simple and applicable to all senile entropion patients.

Aged

Senile entropion. Pathogenesis and treatment.

Lower lid entropion is owing to a defect of the lower eyelid retractors that causes attenuation of the aponeurosis. Twelve patients with lower lid entropion underwent surgery in which a procedure that reapproximates normal lower lid anatomy was used. There were two recurrences of the entropion condition in the twelve patients.

Aged

Senile entropion.

A new surgical procedure has been developed for the correction of senile entropion of the lower lid. The procedure consists of horizontal shortening of the lower lid by a pentagonal wedge resection combined with an infratarsal eyelid suture technique. Twenty eyelids of 13 patients with entropion have been operated on over the last 4 1/2 years with use of various modificatons of this procedure. The average follow-up period is two years three months, with the longest being 4 1/2 years and the shortest being three months. There has only been one temporary recurrence and no overcorrections. The technique is simple and effective when applied to chronic senile entropion unassociated with severe enophthalmos or any cicatricial component.

Aged

Aponeurosis disinsertion in congenital entropion.

Lower lid retractor aponeurosis disinsertion is a well-recognized etiologic factor in many involutional entropion cases, but to our knowledge it has not previously been reported as a cause of congenital entropion. Four congenitally entropic lower eyelids in three patients with no history of birth trauma were all found to have retractor disinsertion during exploratory procedures. All four eyelids were surgically corrected by reinserting the retractors to the inferior tarsal margin. Detailed histologic studies of orbicularis oculi muscle fibers in two cases showed no evidence of fiber hypertrophy. This finding refutes the commonly accepted concept of orbicularis muscle hypertrophy as an etiologic mechanism of congenital entropion.

Child